Minimal fault findings for London Borough of Hackney in its response to safeguarding referrals, and a finding to develop its policy of communications management for complainants.

Decision date: 07/02/20

What happened

Ms C was an elderly woman who was provided care at home by an agency commissioned by the Council. Her daughter, Ms B, spoke to a nurse and raised concerns about the quality of care that the agency was providing. The nurse made a safeguarding referral to the Council, who agreed to provide Ms C with a different agency whilst the first one conducted an internal investigation. This resulted in the dismissal of staff members, improvements to service quality and the sending of an apology letter to Ms B, whereupon the Council closed the investigation.

Ms C was admitted to hospital (hospital 1) for a lengthy stay in mid 2017. The hospital made another safeguarding referral after observing Ms C displaying verbally abusive behaviour to her mother and to staff. The concerns were upheld.

Ms C was taken to a day appointment at a separate hospital (hospital 2) in September who made a further two safeguarding referrals regarding hospital 1. The referrers said that Ms B had found her mother unaccompanied at reception, wearing a hospital gown with no shoes or coat. She had bruising on her upper arms and had not received her morning dose of insulin.

The Council held a safeguarding meeting in January 2018 but had to cut it short due to Ms B’s behaviour (The report stated that Ms B was not allowing other people to speak and was not allowing the meeting to proceed in an orderly manner). Another safeguarding meeting was held shortly after in which Ms B told the Council that she felt hospital 1’s mistreatment was personal and as a result of the many concerns that she had raised with them. She had been banned from hospital 1 and so the Council considered exploring an alternative primary hospital for her.

Hospital 1 made a safeguarding referral (its second, but the fourth overall) due to Ms B’s continued abusive behaviour. 

The Adult Community Rehabilitation Team made a safeguarding referral in January 2018 regarding Ms B’s obstruction of health and care services being provided to Ms C.

The district nursing team made a safeguarding referral regarding Ms B in February. Ms C had suffered a burn which needed daily treatment. The district nursing team was concerned about the safety of the nurses attending the property while Ms B was present following an incident between Ms B and one of the nurses. The team asked Ms B not to be at the property when the nurses provided care but Ms B refused. This meant the nursing team was unable to provide care for several days.

Ms C sadly died in March 2018. The Council decided not to pursue its investigations into the remaining open safeguarding referrals against Ms B, for reasons not explained in the report. 

In a meeting between Ms B and the Council in April, she attributed her mother’s death to the Council’s improper response to the numerous safeguarding referrals. The Council explored each referral with her and directed her to the Ombudsman if she was unhappy with its actions. Another meeting was held in May which resulted in the Council agreeing to refer the case to the Safeguarding Adults Board (SAB). The SAB wrote to Ms B in July to say that it had unanimously agreed that the criteria for a review had not been met and that there was no evidence to suggest that Ms C’s death was due to abuse or neglect.

Ms B continued to raise complaints with the Council. The adult social care team restricted her contact with the Council to a single point: a senior manager that she could only email.

Between the 10th and 23rd of July Ms B made at least 60 calls to various departments of the Council and said that she would not stop calling until she was able to speak with someone. The Council wrote to her on the 25th of July to say that due to her aggressive behaviour and inability to stick to the communication plan it had given her, it was terminating all contact with her. Again it directed her to the Ombudsman.

Ms B visited the Council offices the next day and was allegedly abusive to staff before the police were called. The customer service team informed her that she would be banned from attending the Service Centre without a pre-booked appointment for 12 months. The Council’s legal team wrote to her in September to issue a warning letter that she was not to contact Council staff or the SAB in relation to this matter. It threatened legal action and an injunction if she failed to adhere to this but said if she had social care needs she could contact the Council where she was ordinarily resident. 

What was found

The Ombudsman found fault in London Borough of Hackney Council for a month’s delay in actioning the enquiry it started about hospital 1 following the two safeguarding referrals sent by hospital 2; the guidelines give 5 days.

The LGSCO found the council at fault for failing to be clear as to how it determined Ms B’s ordinary residence. She had indicated that she had care and support needs, therefore the council ought to have informed her as to how it reached this decision, which was fault. 

The Ombudsman found no fault in the Council’s restriction of communications with Ms B. A lot of her complaints were unclear, aggressive and were centred around previous complaints that had been upheld. Furthermore, the Council’s Adult Social Care Team followed proper procedure and offered her a route of communication that did not affect other service users. 

The Council was also at fault for failing to give end dates on all but one of the restrictions it imposed on Ms B.


Within one month, the Council would:

  • Review the restrictions placed on Ms B’s contact with it;
  • Send a letter to Ms B to apologise for the injustice it caused her, to inform her of the outcome of the review and to explain how it considered the Care Act Guidance when making the decision to restrict her contact;
  • Ensure that any further restrictions have a timescale and a review date set and;
  • Review the decision as to ordinary residence and inform Ms B how it considered the care Act guidance regarding ordinary residence when making its decision.  

Points for the public, charging officers, financial affairs officers, service users, family members and advocates

This complaint involved seven safeguarding referrals, 3 of which pertained to the actions of the complainant and were not considered by the LGSCO. It highlights the way in which councils need to act promptly in response to safeguarding referrals – taking a month when the guidelines state 5 days is clearly going to be too long especially where a vulnerable person is at risk of harm. 

The complainant’s mother was the person at the heart of these referrals. The council was not found at fault for the actions it took in relation to the safeguarding referrals and it was identified that although Ms C passed away, the situation did not meet the criteria for a review by the Safeguarding Adults Board. 

The complainant disagreed with these actions and through her attempts to raise concerns the council found it necessary to restrict her contact with its officers. The council in this complaint did not have a policy that supported it sufficiently to manage the contact received by the complainant, which led to the LGSCO recommendation that it ensure that it gives a timescale for review of any future restrictions for complainants. 

The LGSCO provides support to councils in understanding the need for such policies and the link to this guidance can be found here:

The final issue with this complaint relates to ordinary residence. Ms B was told by the council to seek support from the local authority area in which she is resident. ‘Ordinary residence’ is not explicitly defined in the Care Act 2014, therefore the phrase should take its normal meaning. it is a relevant term when someone is living in one area and seeking the support of a local authority in another area, or when someone moves between areas and informs the decision as to whether a council has to meet eligible needs of a person. 

The Care and Support statutory guidance (paragraph 19.15) says this:

Local authorities should in particular apply the principle that ordinary residence is the place the person has voluntarily adopted for a settled purpose, whether for a short or long duration. Ordinary residence can be acquired as soon as the person moves to an area, if their move is voluntary and for settled purposes, irrespective of whether they own, or have an interest in a property in another local authority area. There is no minimum period in which a person has to be living in a particular place for them to be considered ordinarily resident there, because it depends on the nature and quality of the connection with the new place.

Whilst the LGSCO report contains little information about the decision itself, the council still should have told Ms B the basis for its decision-making and made clear to her any right to challenge the decision. 

If you want help, please consider seeking advice from CASCAIDr via our referral form on the top bar menu of the site.

The full Local Government Ombudsman report on the actions of London Borough of Hackney Council can be found here:

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